APPLICATION FOR WATER SYSTEMS EXAMINATION



APPLICATION FOR CERTIFICATION FOR INDIVIDUALS WITH MILITARY TRAINING AND EXPERIENCE464820088900REQUIREDPlease attach a copy of:VMETHS Diploma or Equivalent00REQUIREDPlease attach a copy of:VMETHS Diploma or EquivalentInstructions: PLEASE PRINT OR TYPE1)Carefully and completely fill out the entire application. 2)Application must be typed/printed in ink and mailed to: NCWTFOCB or NC Water Treatment Facility Oper. Cert. Board1635 Mail Service CenterRaleigh, NC 27699-16353)Administrative processing fee is $50.00 and non-refundable. Branch of Service FORMCHECKBOX ARMY FORMCHECKBOX NAVY FORMCHECKBOX AIR FORCE FORMCHECKBOX MARINE FORMCHECKBOX NATIONAL GUARD FORMCHECKBOX OTHEREXAM SELECTION (A level is the highest): FORMCHECKBOX Cross-Connection FORMCHECKBOX Distribution FORMCHECKBOX A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D FORMCHECKBOX Surface FORMCHECKBOX A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Well FORMCHECKBOX A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX DApplicant Name: FORMCHECKBOX Mr. FORMCHECKBOX Mrs. FORMCHECKBOX Ms.SSN# (Required) FORMTEXT ?????- FORMTEXT ?????- FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameMiddle InitialLast (Jr. Sr. etc.) FORMTEXT ?????Mailing Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CityStateZipE-Mail Address: FORMTEXT ?????Telephone #: FORMTEXT ?????Military Experience Details:LocationDatesPopulation Served or Number of Connections FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Civilian Experience:SystemDatesPopulation Served or Number of Connections FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(Attach Additional Sheets if Necessary)DISCLAIMER: The North Carolina Water Treatment Facility Operators Certification Board (the Board) is the final authority on all decisions relating to the treatment of water in North Carolina. The Board has the authority to make decisions based on applicant’s military experience and work history to determine the type and level of exam the applicant is qualified to sit for and their decisions are final and binding. The Board may determine that an application is not qualified to take the level of exam they requested and determine they need to sit for a lower level exam. The applicant has the right to refuse to sit for the level the Board determined. However, the administrative fee is NON-REFUNDABLE. FORMCHECKBOX I (please print) have read the above disclaimer and understand the administrative fee is non-refundable.Applicant Signature: (Required)OFFICE USE ONLY FORMCHECKBOX Approved FORMCHECKBOX DeniedBoard Issued ID# ................
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